Declaration of Criminal Records and Fitness to Study and Practice

 The following questions are designed to help us assess your suitability to undertake the BSc (Honours) degree in Acupuncture. Such questions form part of the normal application process in organisations such as the British Acupuncture Council, and have been adopted by all accredited acupuncture colleges and courses based in the UK.

Please ensure that you fully disclose all material facts. If you are uncertain as to the relevance of any particular fact, you should disclose it. The information requested here will be treated in strict confidence and may not be divulged to a third party without your knowledge and consent.

Completion of this form is essential for you to be able to commence the programme. Non-disclosure and subsequent discovery of a conviction is regarded seriously.

Your answers will also enable us to give you guidance about your eligibility to register, once you have qualified, with the British Acupuncture Council or in future with a statutory register. However, we cannot guarantee this since the final decision rests with the BAcC/statutory register.


Part A Criminal and civil proceedings

i) Have you ever been under investigation or convicted of any criminal offence?


If ‘yes’, please give details on a separate sheet and include the date of criminal proceedings, the date of conviction and the judgment you were given.

(Professional organisations such as those governing the acupuncture profession, whose members work with children, the elderly or vulnerable adults, are exempt from the provisions of the Rehabilitation of Offenders Act 1974. You must inform us of all convictions, including those that would otherwise be considered spent.)


ii) Have you ever been involved, or are you currently involved, in civil proceedings in matters relating to any professional practice or business in which you are or have been engaged?


If ‘yes’, please state on a separate sheet the nature of these proceedings and whether any judgment was made against you. 


iii) Have you ever been subject to any disciplinary proceedings and/or findings against you by any professional healthcare register or other professional register or association, any teaching institution or government authority, whether international, national or local?


 If ‘yes’, please give details on a separate sheet of the date when this happened, the nature of the complaint against you and what action was taken or is pending as a result.


iv) Have you ever voluntarily surrendered a licence to practise any healthcare practice, or resigned or been suspended, or been referred for remedial training, in lieu of disciplinary proceedings being taken against you, including your time in education and training?


If ‘yes’, please give full details of the circumstances on a separate sheet.



Part B Fitness to Study and Practise

i) Do you have or have you had an emotional disturbance or psychological illness which might reasonably be considered to impair your ability to study and/or practise acupuncture or any other healthcare profession?


ii) Do you have or have you had a physical illness which might reasonably be considered to impair your ability to study and/or practise acupuncture or any other healthcare profession?


iii) Are you now, or have you been in the past, dependent on alcohol or drugs?


If ‘yes’ is the answer to any of these questions please give details on a separate sheet of the type of condition for which you receive(d) treatment, the dates and the type of organisation(s) responsible for your treatment

iv) Do you have any disability which might reasonably be considered to affect either your ability to practise as an acupuncturist or your ability to complete any of the requirements of the course you are applying to join?


If ‘yes’, please give details on a separate sheet together with details of any special aids or equipment which you might need to study and/or practise acupuncture.

v) Do you have a medical condition, e.g. diabetes, epilepsy, heart condition that might require attention during your time as a student?


If ‘yes’, please give details on a separate sheet together with details of any care that it might be appropriate for College staff to be aware of.



I …………………………. hereby certify that the information provided above is accurate and complete in all respects. I understand that making false or misleading statements, or failing to disclose all material facts, could result in my being suspended or removed from the BSc. Honours degree in Acupuncture.

Signed ………………………………. Date …………………………..




Guidance Notes

Please read the following notes carefully before completing this declaration form. If you require further information, please contact Peter Mole All enquiries will be dealt with in confidence at this stage.

The College of Integrated Chinese Medicine aims to promote equality of opportunity and is committed to treating all applicants fairly and on merit. We undertake not to discriminate unfairly against applicants because of criminal conviction or other information declared.

We will discuss with you any declared information that we believe has a bearing on your suitability for the programme, and your future qualification.

The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998 and the EU General Data Protection Regulation 2018 and will only be used for determining your position on the programme. Once a decision has been made, we will not retain this form for any longer than is necessary (usually 10 weeks) and it will be destroyed at the end of the initial process.

The declaration form will be kept securely and in confidence. Access to it will be restricted to designated persons within the institution. These people are Angela Hicks and Peter Mole.


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Please note: you must inform us immediately if you are charged with any offence in the United Kingdom or in any other country after you complete this form and before you commence practice. You do not need to tell us if you are charged with a parking offence or a speeding offence unless you are disqualified as a result.